Atrophy of Inner Thigh

[BrownTrout]

Been a runner for many, many years. Up until 1990 that is. Had my first surgery to the lumbar region to address a lower back problem. Since then I've had six other surgeries to the lumbar region, including three lumbar disks fusions. Needless to say, my running, golfing and other activities have ceased since 1990.

After surgery one year ago to address an extremely painful pinched nerve (L3 - L4 as I recall) my right inner thigh just above the knee has atrophied 1.5 inches relative to the left thigh. Went to a PT and he said he couldn't help me because he thought my issue was related to the Iliopsis (sp) muscle and that muscle doesn't respond to physical therapy.

Went to an MD at the University who specializes in this stuff and he did all kinds of tests with electrical devices, needles and other test and said my right leg just didn't respond well to any of the tests. Went back to my neurosurgeon and he wanted to do another MRI to see if he hadn't removed all the matter pinching tht nerve. If not, he wanted to operate again :-(

So I gave up on the "professionals" and I've been trying to do my own PT. Riding a stationary bike forward and backward. Doing squats, walking up/down steps, leg raises, etc. Left leg is now much stronger but the right leg continues to atrophy.

Any ideas on how I can rehabilitate that darn right thigh with exercises, electrical stimulation or whatever? Any and all thoughts would be much appreciated!

Jim

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[Dr Damien]

Dear Troutbrown

Some of my colleagues may not agree with me on this but I think this problem just might be straight forward. Although i dont see what the real problem is, you havent reported any pain or any functional difficulties...what you are sort off reporting are cosmetic issues.

The area you are reporting corresponds to the belly of the adductor group of muscles. This muscle is innervated by the obturator nerve with origins from the lumber spine, some portions come from the sciatic nerve. you have had various EMG testing which seems to appear anything but normal. You have also had various surgeries to your spine...but you continue to have ongoing atrophy of the muscle group, do you have any numbness? can you adduct your leg easily...compared to the other one? try lying on your side of the problem leg, keep it straight and try to lift it upwards towards the other leg, repeat with othe side...

If you are having problems with this and you have numbness then maybe you have suffered a resected nerve...if its just weak and there is numbness then maybe you are a nerve compression of the obturator nerve...in both cases continual atrophy will occur...and no amount of exercises is likely to help...

so perhaps wait for the MRI...in the meantime you can keep trying to exercise that muscle group to slow down the process of atrophy but like i said it is unlikely to stop it...
since you have had fusion of the discs im not sure attempting to mobilize your lumbar spine will make a difference...but you can try this with another physio, the assessment will include comparing the symmetry of both sides of your lumbar spine and pelvis...the initial physio may be right to think the issue is with the iliopsoas muscle..if its really tight, on one side...then it can compress structures from the lumbar spine there...

with the right assessment, you may be able to achieve some improvement with mobilization, stretches and electrical stimulation..but i see a very long rehabilitation period...

[BrownTrout]

Dr. Damien,
Forgot to mention a few particulars. Yes, there is considerable numbness in the right leg from the hip area down the right side to the knee where it crosses over to the inside of the leg and extends down to the ankle region. The pain I experience is moderate but persistent in the lower back and the area around the right knee. I also experience a "stinging" in both sides of the hip area which two professionals have said is related to the facets (sp)?

The weakness of the right leg is quite obvious while walking, climbing stairs, riding the stationary bike and doing various floor exercises. Within a month or two after the surgery, the right leg would not support my weight (195#) which resulted in two instances of falling while (1) walking backwards while moving a water hose and (2) while climbing the steps up to the deck. I'm beyond that now thanks to time and exercise but the weakness is still very prevalent. When I finish riding the stationary bike for 15 minutes, the right leg is extremely weak and climbing the stairs is much more difficult than usual. The numbers on the digital gauge of the stationary bike (e.g. RPM) all show approx a 10% - 15% difference between the two legs with the right being weaker.

I tried the exercise you mentioned. I tested the left leg first and it did fine. But I could only lift the lower end of my right leg off the floor, from the knee to the foot but couldn't lift the thigh.

I don't care how long the rehab will take, I just want to find the right ideas (exercises or whatever) as to how to proceed in a direction that will make some improvement in strength. I assume the exercises I'm doing are appropriate but if you could recommend a few it would be helpful. I've been riding the stationary bike for 15 minutes pedaling both forward and backward, doing squats, leg raises while sitting and standing and walking up down the steps forward and backward.

Jim

[Dr Damien]

Dear Browntrout(Jim)

Your symptoms sound like they are truly originating from L3/L4. Definitely cant give you any exercises without assessing first however some aims of treatment and some goals for rehabilitation can be set:
1) reduce the sensation of numbness experienced (this may not change if it has been a very longstanding problem)
2) improve the strength of the adductor group of muscles
3)decrease pain in the back

Goals from rehabilitation could be lets say for instance
1) to be a ble to climb up and down the stairs with one rail support or no support
2) to be able to climb up and down with a reciprocal pattern
3) reduce risk of falling

when you cycle are you using any resistance or are you riding on the same intensity? sometimes when you ride a bike, there is temporary weakness when the muscle is fatigued...
what you need is progressive strengthening program, that eliminates the possibility of fatigue...i had a patient once who fractured her thigh bone and was in a cast for 6-12 weeks, she also had a history of polio...when we tried to strengthen her thigh muscles by using a stationary bike, she always had a weakness immediately after that made walking difficult, however this weakness did not last...the muscles will get stronger but they need to be challenged appropriately otherwise you will not be building more fibers or firing as much of the fibers as you need...so think about setting the intensity to something comfortable...but not too easy (it should feel difficult butyou should be able to cycle it)...cycle fo short periods...but repeat often...then gradually increase the intensity regularly...
you can also strengthen the adductor muscles specifically by squeezing a ball between your thighs, holding for 10seconds...repeat maybe five times...do often in a day...gradually increase time you squeeze...
you could also lie down on your back, bend the good leg so that the foot is flat...keep the bad leg straight...try to lift off the floor then move it across your body slowly...do five times, gradually build over time...
in time you can can progress this exercise to the test position described in the previous entry...or involve the use of a resistance band

the idea is you need to challenge the muscles to get them to change their physiology, repeating the same intensity will improve to a level then no other improvements will be seen...the ideas ive suggested above are not written in stone...its the idea that is relevant, whatever works for you with regards reps is perhaps what is more approprite

NOTE: these exercises can influence your back, so you need to have your back well supported when doing any leg raises...

Because there is a possibility of some tightness of your iliopsoas muscle...you need a good assessment to see if this is overactive or tight...

You may benefit from some lumbar stabilization exercises...to generally mobilize and strengthen your spine...
some stretches in lying or sideflexion may be required...some therapists are skilled in manual therapy to help release tight muscles

electrical stimulation can be done with a physio in adition to any manual therapy work...to stimulate the nerves and get them to fire...FES may be more appropriate...

you could also try some balance exercises...wherein the aim would be to be able to ultimately one leg stand...with or without minimal support...

if you have goals set in place, and you are achieving them then your rehabilitation is working...you dont have to set the same goals i have suggested, its the goals that mean something to you thats important, I have only picked these goals based on what you seem to have trouble with..

you really need to work with a therapist, you have tried two professionals only...there are therapists out there who are rehab oriented...and can help you achieve any goals you set, its perhaps better to seek the one with core skills in musculoskeletal/manual therapy....

Did you have any physio after your surgeries?

[BrownTrout]

Dr. Damien,
I had successful physical therapies after all my surgeries except this last one a year ago. I went to the PT at the local hospital a couple of months after the surgery and he reviewed the neurosurgeon's notes and told me he couldn't help me. That was very discouraging to hear.

I visited another PT a month ago just to see if he thought he could help. He suggested I roll up a towel and put it under my left waist and just relax on the floor for 5 minutes. Said to repeat this if it provided relief and to quit if it hurt. He thought this would help separate the vertebrae that might still be pinching the sciatic nerve. After the first time, it made matters worse (more pain). Tried it again the next day with the same results so I quit that "exercise".

Just seems like those I've visited with so far truly do not understand the nature of my problem and, therefore, are not providing realistic remedies. Maybe I should just return to the neurosurgeon, get another MRI, have him define the problem for me and recommend therapy from someone in their clinic (Springfield Neurological and Spine Institute in Springfield, MO). I'd have done this already but I feel he will just want to operate again, not to mention it's a 3 hour drive to the clinic.

I've done some of the exercises you mentioned in your last post. For example, squeezing a ball between my thighs. I'll also try some of the others you mentioned.

Jim

[BrownTrout]

Forgot to mention that along with the exercises I've been doing to strengthen the leg, I've been addressing the pain by laying flat on the floor with my legs up on a chair and alternating heat and ice packs. This seems to work . . . . for short periods anyway.

Jim

[alophysio]

hi browntrout - DrDamien has given you some good advice.

I was reading your posts and i couldn't help but wonder why the PTs have given up so easily on you - it may actually be because you have nerve damage. They might have tried to explain this to you but you might not have understood or they might not have been clear to you.

You can do the program as suggested by DrDamien and it will help if that is what your problem is - DrDamien would be the first to acknowledge that we are trying to help you without actually being able to see you.

My thoughts are in addition (not in opposition) to his...

I think your statement of saying that no one truly understands the nature of your problem is spot on. I think what you are lacking is a good diagnosis of the problem. Now it may be as simple as weakness that needs to be addressed but i think it is more muiltifactorial than that.

It would seem to me that your nerves are compromised somehow and that is causing all sorts of problems in your body. Because of the nerves involved, it would seem that your adductors or your VMO is the problem.

Your iliopsoas might be overactive and trying to substitute for your adductors. It is a stubborn muscle but it will yield if you take away the reason why it is overactive in the first place

My main impression reading your posts are that your back is affecting the nerves in your back and you probably lack the control of the back following the surgeries and falls. The other thing is that you haven't actually told us why you needed all those surgeries (esp the first one). Was there an accident? What were the other 3 surgeries if 3 of them were fusions?

Also, it is well known/documentated that fusion of a lumbar level will almost certainly lead to failure of discs of the joints above and below the fusion. Since 1990 is over 20 years ago, i suspect your spine isn't in fantastic shape. It is likely that excessive bone growth or excessive movement due to disc degeneration is causing issues.

Also, your MD is tests with electrical devices but you don't mention if they were EMG tests. They are like zaps to your muscles and measure your nerves and their conduction velocities etc. You said that your muscles didn't respond to the tests but did that mean the tests showed nothing or that the muscles were gone and not responding like they should (a positive test).

Thanks!

[BrownTrout]

Here is my back surgery history:
1990 - Went to orthopedic surgeon for minor pain in lower back after a long run (~12 miles). He did an MRI and said I had a slipped disc which could be corrected with surgery (laminectomy?). He did the surgery, I did the rest period of several months and walked every day for PT. After f/u visit, he said resume your running. Ran gently for less than a mile and had to limp back home in pain. Went back to the doctor and he said he'd done all he could.
1990 - Got a another MRI and a myelogram from a neurosurgeon who said I had a slipped disc. He said he'd been trained in microsurgery in England and could fix the problem using this type of surgery. He did the surgery and I was in more pain afterwards than before the surgery. Legs would barely support me standing up. He later told me he could give me cortisone shots but that's all he could do.
1991 - Went to another neurosurgeon who did another MRI and said I had a bad disc and a pinched nerve. He did the surgery and it actually provided much relief. However, he said no more running, golfing or softball. Only walking and minor weights.
2004 -While bending over pulling a seat out from the deck of my bass boat, I felt a stinging pain. Eventually, my left leg went numb and started tingling. My local doctor said I had sciatica and prescribed pain pills. Eventually I ended up in the office of a neurosurgeon who, after reading another MRI, said I had a pinched nerve and put me in the hospital the next morning for surgery. This surgery went very well although I had some residual numbness in the left foot that is still there today. He said this was because I suffered this pinched nerve for 3 months before coming to him.
2007 - Started having severe lower back pain again. MRI should considerable problems and a neurosurgeon at the Springfield Neurological & Spine Institute said he recommended fusing both the L2 - L3 and L3 - L4. Said with all the previous surgeries (laminectomy/discectomy) in that region of my back the fusion was necessary. He did the work and I went for several months PT. Still retained minor lower back pain but it was tolerable.
2010 - Started experiencing severe back pain. The pain was overwhelming when I got out of bed in the morning when I tried to walk. It was so severe I simply laid on the floor with tears in my eyes praying for relief. Went back to the SNSI who did an X-Ray and an MRI and scheduled me for surgery two days later to relieve what he said was a severely pinched nerve in the L3 - L4 region. Did the surgery but it did NOT fix the problem. I knew it when I awoke in post-op but the surgeon said it was probably swollen and would take a few days before I would get relief. NOT!
Two Weeks Later - That same surgeon said he must not have removed all the material that was pinching the nerve so he scheduled me for another surgery. That surgery eliminated most of the dreadful pain and allowed me to walk again and get around. But, to this day, I still have a minor pain in the lower back, right leg atrophying, numbness in the right leg and occasional feeling around the right knee that I have spilled ice water on the leg. These are the symptoms I am currently experiencing.
Three Months Later - Visited the MD at the University (Physiologist?) who conducted the EMG tests.

I feel like I've been victim of the medical system that is here, supposedly, to heal people. And yet, look at the condition I'm in after seven back surgeries.

That's my story. Hopes this helps answer your question about my history. Just wish I could ID a muscle group or whatever that I should work on to address the problem with the right leg. It's that or return to a neurosurgeon for, no doubt, another recommended surgery.

Medical Equipment used: Wore a very expensive, custom fit back brace for 90 days after the 2-disc fusion in 2007. The MD who conducted the EMG tests, prescribed a leg brace that fit inside the right shoe and strapped to the leg below the knee. Wore this for two months but it really didn't accomplish anything that I could tell. For the first three months following the two surgeries in 2010, I had to use first a walker to get around and then a cane.

One point that might be a clue to the problem muscle group is that, for quite awhile following surgery, I could drive my truck. I could not lift my right leg very well from the accelerator to the brake so I couldn't trust myself to drive. With the help of exercises and time I can now drive and walk quite well.

Finally, yes, the tests I had done at the University were the EMG tests and, according to the MD who did quite a few tests along with a med student, the tests showed very low results compared to normal. They had to repeat the same tests 2 or 3 times because the readings were so low but they all showed the same low results each time.

Jim

[Dr Damien]

Dear Browntrout

LOng history, started off with minor back pain in 1990. Maybe a physio/chiro should have been the first choice before surgery,

YOu have had all these surgeries, scar tissue, excess bone growth, spinal instabilities from damaged supporting ligaments, poor spinal stabilizers all might be adding to the problems. YOu mentioned that once you bent to pull a seat out of a the deck of a bass boat and you had severe pain. you definitely have a very unstable spine hence the indication for fusion...

you mention that heat/cold helps...i presume this helps with the muscle spasm...

Are you able to bend forward? are you able to bend backwards? which causes more pain...?which relieves it? is the minor pain constant now? does it respond to movement? the numbness or ice cold feeling? do they come with movement or positions? if any of these symptoms are influenced by movement then maybe a manual therapist could be of help? if they are just constant sensations...then im not too sure,,...

you say putting a pillow roll under your left waist increases the pain...mmmmm...

you just may improve with a really detailed assessment...

[BrownTrout]

If I could ID the specific muscle or muscle group that has atrophied and I did progressive exercises to that muscle, wouldn't it improve over time? Would it improve even if the nerve in the lower back related to this muscle is still pinched a little?

The atrophy of the right leg starts immediately to the left (inside) of the knee cap and extends up the thigh about 6 or 7 inches. This inside muscle "sags" relative to that same area on the left leg. Due to this atrophy, the knee cap is very prominent relative to the left knee cap. If you know which muscle this is, what would be the best exercise to work this muscle? Is this the vastus medialis? The sartorius? Or what?

Jim

[alophysio]

Hi Browntrout,

In my honest opinion, searching for the "specific" muscle/s is a futile exercise. Very rarely does a muscle or muscles cause all the issues.

Also, the nerve to the muscles of your inner thigh appears to be compromised...what you propose is like trying to turn the lights on at the switch even though the electrician has cut the wiring to the lights...If the nerve is compromised, only the function it has left is usable. In some cases alternative wirings can occur but in your case, i think it is a very long shot.

In answer to your question, it would seem like the muscle you are referring to is the vastus medialis but again,building it up doesn't change things. You have had all sorts of tests which specialists believe is affecting your nerves.

I do not want to take your hope away...I merely want to present a balanced view of things. Based on the information you have given, the fact that you are 69, the 7 disc operations you have had, what we know when discs get injured and lumbar joints fused, your EMG results, the fact that you are trying to do everything you can etc etc, without seeing you in person, i would have to say that the picture is bleak.

Of course, i could be wrong

Please seek some in-person advice about the whole of your story, not just the symptoms. Find someone to explain the whole journey you have taken and explain what might be ahead and what you can do to help.

it is very obvious that you are committed and keen and willing to do what it takes to get better...i could only wish some patients of mine had the same attitude

Thanks.